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Geographic Access to COVID-19 Healthcare in Brazil Using a Balanced Float Catchment Area Approach

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Geographic Access to COVID-19 Healthcare in Brazil Using a Balanced Float Catchment Area Approach medRxiv preprint doi: https://doi.org/10.1101/2020.07.17.20156505; this version posted July 19, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . Preprint July 2020 Geographic access to COVID-19 healthcare in Brazil using a balanced float catchment area approach Rafael H. M. Pereira* Carlos Kauê Vieira Braga Luciana Mendes Servo Institute for Applied Economic Research - Ipea, Brazil Bernardo Serra Institute for Transport Policy & Development - ITDP Brazil, Brazil Pedro Amaral Universidade Federal de Minas Gerais (UFMG), Brazil Nelson Gouveia University of São Paulo Medical School (FMUSP), Brazil Antonio Paez McMaster University, Canada Abstract: The rapid spread of the new coronavirus across the world has raised concerns about the responsiveness of cities and healthcare systems during pandemics. Recent studies try to model how the number of COVID- 19 infections will likely grow and impact the demand for hospitalization services at national and regional levels. However, less attention has been paid to the geographic access to COVID-19 healthcare services and to the response capacity of hospitals at the local level, particularly in urban areas in the Global South. This paper shows how transport accessibility analysis can provide actionable information to help improve healthcare coverage and responsiveness. It analyzes accessibility to COVID-19 healthcare at high spatial resolution in the 20 largest cities of Brazil. Using network-distance metrics, we estimate the vulnerable population living in areas with poor access to healthcare facilities that could either screen or hospitalize COVID-19 patients. We then use a new balanced floating catchment area (BFCA) indicator to estimate spatial, income and racial inequalities in access to hospitals with intensive care unit (ICU) beds and mechanical ventilators while taking into account congestion effects. Based on this analysis, we identify substantial social and spatial inequalities in access to health services during the pandemic. The availability of ICU equipment varies considerably between cities and it is substantially lower among black and poor communities. The study maps territorial inequalities in healthcare access and reflects on different policy lessons that can be learned for other countries based on the Brazilian case. Keywords: COVID-19, Healthcare accessibility, Brazil Balanced Float Catchment Area * Corresponding author: [email protected] 1 NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice. medRxiv preprint doi: https://doi.org/10.1101/2020.07.17.20156505; this version posted July 19, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . Preprint July 2020 1. Introduction The global outbreak of the new coronavirus (SARS-CoV-2) has raised serious concerns about the responsiveness of healthcare systems and particularly about how vulnerable population groups might be affected (Lancet, 2020; WHO, 2020). A rapidly growing body of research has emerged to model how the number of COVID-19 infections will likely grow and impact the demand for hospitalization services globally (Petropoulos & Makridakis, 2020; Walter et al, 2020) and at the national level (Arenas et al., 2020; Moghadas et al., 2020; Paez, 2020; Paez et al., n.d.; Wu, Leung, & Leung, 2020). However, less attention has been paid to the geographic access to COVID-19 healthcare services and to the response capacity of hospitals at the local level in urban areas, despite the potential relationships between accessibility to healthcare resources and mortality (Ji, Ma, Peppelenbosch, & Pan, 2020). Early work by Ji et al. (2020) and Rader et al. (2020), for example, considered resources at the provincial level in China and at the county level in the USA, but we are not aware of studies that investigate the issue of resource allocation at higher spatial resolutions, particularly in the context of Latin America, where the epicenter of the pandemic shifted in June, 2020. The goal of this study is to present estimates of geographic accessibility to COVID-19 healthcare at high spatial resolution in the 20 largest cities of Brazil. Healthcare services in Brazil are known to be unevenly distributed across the country and also within cities (Amaral et al., 2017). In this context, it is crucial to map where vulnerable social groups confront poor accessibility to health services. Similarly, it becomes paramount to identify which healthcare facilities are likely to face surges in demand due to the need to hospitalize severely ill patients. In this paper we combine traditional and novel accessibility metrics to address these questions. Using network- distance metrics, we first estimate the number of vulnerable people living in areas with poor access to inpatient or outpatient facilities able to provide care for patients with suspected or confirmed cases of COVID-19. Next, we use a new balanced floating catchment area method (BFCA) proposed by (Paez, Higgins, & Vivona, 2019) to analyze levels of access to hospitals that could treat patients with severe symptoms of COVID-19, taking into account healthcare system capacity and competition effects for ICU beds with mechanical ventilators. 2 medRxiv preprint doi: https://doi.org/10.1101/2020.07.17.20156505; this version posted July 19, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . Preprint July 2020 The results of this research are useful to identify, in the 20 cities examined, a population of approximately 1.6 million people who live more than 5 km away from a healthcare facility equipped to treat severe cases of COVID-19. Furthermore, although overall the average number of intensive care units (ICU)beds with ventilators is 1.06 per 10 thousand inhabitants, there are large variations in this level of service, both between and within cities. In particular, we find that the accessibility to ICU resources is substantially lower in black and poor communities. This creates a worrying scenario given the strong potential for propagation of COVID-19 combined with poor health outcomes. The study maps territorial inequalities in healthcare access and reflects on different policies that could be adopted to address them. The remainder of this paper is as follows. The next section provides relevant background information regarding the evolution of the COVID-19 pandemic in Brazil and accessibility analysis. This is followed by a discussion of the data and methods used in this research. Then, the results of the empirical analysis are presented and discussed. And finally, we offer some concluding remarks, including policy implications and directions for future research. 2. Background 2.1 COVID-19 in Brazil The first confirmed case of COVID-19 in Latin America was in late February 2020, in Brazil. The affected person was a man from São Paulo who had travelled that month to Italy. This case was typical of the beginning of the epidemic in Brazil, with other early cases of the disease imported via international flights coming mostly from Italy and the United States (Candido et al., 2020). At that early stage, the then-Minister of Health noted that it would remain to be seen how the virus behaved in a tropical country in the middle of summer. While there is evidence that incidence of the disease is lower at higher temperatures (Paez et al., 2020), it is now clear that the disease can be devastating during summer too: as early of July, less than five months after the first confirmed case of the COVID-19 in Brazil, over 1.8 million cases have been confirmed, and over 70 thousand deaths have been attributed to the disease, 45% of which concentrated in the 20 largest cities of the country. By early June, Brazil had become, after the United States, the country with the highest number of cases of COVID-19 in the world. 3 medRxiv preprint doi: https://doi.org/10.1101/2020.07.17.20156505; this version posted July 19, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license . Preprint July 2020 The earliest cases of COVID-19 in Brazil were concentrated among middle and upper- class people (Souza et al., 2020). In Brazil’s mixed health care system, these segments of the population typically can afford to pay for healthcare or use health services intermediated by private health insurance. This is not the case for lower-income groups, who are largely dependent on the public health system in Brazil, and among whom community transmission rapidly increased the number of infections. This development is particularly worrisome as low-income groups in the country also typically live in less developed urban areas with poor transport services and poor access to health, education, and employment opportunities (Pereira, Braga, Serra, & Nadalin, 2019). Previous research, in fact, has identified important spatial gaps in accessibility to emergency services in Brazil (Rocha et al., 2017). To further complicate matters, other research has linked poor accessibility to higher pneumonia mortality (Zaman et al., 2014). Given the rapid growth of COVID-19 in Brazil, it is important to map the potential stress on the country’s healthcare system.
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